Unusual Cause of Abdominal Swelling in an Infant with Esophageal Atresia-Tracheoesophageal Fistula: Case Report
Genco Gençay1*, Abdülkadir Baziki2, Feryal Gün Soysal3,/sup>, Demet Demirkol4
¹Fellow, Istanbul Faculty of Medicine, Department of Pediatric Intensive Care, Istanbul, Turkey.
²Resident, Istanbul Faculty of Medicine, Department of Pediatric Surgery, Istanbul, Turkey.
³Professor, Istanbul Faculty of Medicine, Department of Pediatric Surgery, Istanbul, Turkey.
⁴Professor, Istanbul Faculty of Medicine, Department of Pediatric Intensive Care, Istanbul, Turkey.
*Corresponding author
*Ali Genco Gençay, Fellow, Istanbul Faculty of Medicine, Department of Pediatric Intensive Care, Istanbul, Turkey. Email: gencogencay@gmail.com
DOI: 10.55920/JCRMHS.2024.07.001309
Abstract
Purpose: We examined the morphological factors affecting the growing foetus’ heart, the fetal and maternal relations of pregnancies complicated by diabetes mellitus. We seaked the severity of myocardium hyperplasia is in correlation with infant respiratory distress syndrome and cardiac failure.Our study was a prospective case- control study of pregnancies complicated by diabetes mellitus produce fetal myocardium hyperplasia.
Methods: Two ultrasound examinations were carried out on 84 pregnant women, in accordance with the selection criteria (different types of diabetes mellitus and controll cases).
The first ultrasound examination was carried out between the 24-28th weeks, the second between the 33-38th weeks of pregnancy. During the examinations we measured and averaged the fetal sizes, the estimated fetal weight, the quantity of amniotic fluid and the thickness of the ventricles and interventricular septum. Besides, we collected data from pregnant women in connection with the symptoms of diabetes mellitus, plus followed the outcome of these pregnancies. We compared these data againstthe ourcontrolgroup and a literature reference group.
Results: Regarding the fetal myocardium and the interventricular septum, significantly higher values were registered compared to the control group, and 21% of the infants are macrosomic, 16%of them were born with intrauterine growth restriction.
Conclusions: Based on the examinations we concluded that more complications occurred to foetuses and infants of obese pregnant women and those with diabetes mellitus than in the control groups. Thus, following the fetal myocardium’s parameters in the perinatal outcome of the mother’s glucose system’s discrepancies can be a well-applicable filtering method.
Keywords: Cardiac Function, Fetus, Gestational Diabetes Mellitus, Pregnancy, Prenatal Ultrasound
List of abbreviations
BMI: body mass index
EDV: end-diastolic volume
EWF: estimated fetal weight
GDM: gestational diabetes mellitus
IRDS: infant respiratory distress syndrome
IUGR: intrauterine growth restriction
NIC: neonatal intensive centre
OGTT: oral glucose tolerance test
PI: pulsatility index
PSV: peak systolic velocity
SD: standard deviation
UH: ultrasound
Vmean: mean volume of systolic and diastolic velocities
WHO: World Health Organisation
Introduction
Diabetes mellitus has become an endemic disease. While the occurrence of Types 1 and 2 in fertile women is 0,5-1,0%[1,2], gestational diabetes mellitus(GDM) diagnosed during pregnancy is present in 10-30% in Europe [1,2], making itthe most common medical complications during pregnancy [3,4,5].Showed an increase in the GDM incidence from 12.4% in 2009 to 18.5% in 2017 in Hungary [5].
In our research we highlighted the examination of the relation between the fetal myocardium and the GDM. In case of GDM, the development of temporary fetal myocardium hyperplasia occurs inapproximately 25%, the severity of which is in direct proportion to infant respiratory distress syndrome (IRDS), as well as to atonic cardiac failure[6].
The mail goals of study are:
- Our main objective is the examination of fetal myocardium, since we wished to examine he prevalence in case of diabetic pregnant women in Hungarian population, too. We prepared the ultrasound examinations twice: in 2nd and 3rd Therefore we want to seek the first detection date of myocardial problem.
- Follow-up of fetal biometric parameters and complications.
- Analysis of circulatory relations of uterinal and umbilical arteries.
- Registration of infancy adapting phenomena.
Consequently, in our study we wish to elaborate on and summarise the experiences and findings registered during our research: the effects of various forms of obesity and diabetes mellitus on fetal myocardium compared to pregnancies without complications, including our control group and ones listed in the literature. With the help of our research, we would like to call attention to these, possibly severe pathological processes and to help preserve the health of pregnant women and their children to be born.
Material and method
As a result of our research, altogether 84 pregnant women were included in our examinations during a year period. We looked for participants amongst prenatal care- and hospitalised patients at the Obstetrics and Gynaecology Clinic, University of Szeged, based on the criteria set. The pregnancies were separated into two groups: a normal control group (n=44) and an GDM group (n=40).
Material and method/ Documentation
After orientation and reading an Ethical Committee-approved patients’ guide, the participating pregnant women signed a document of consent, then they filled in a datasheet related to their pregnancy and diabetes mellitus, while having an in-depth conversation.
Material and method/Ultrasound examination
Two ultrasound examinations were carried out: one between the 24-28th, and one between the 32-38thweeks of pregnancy. The abdominal ultrasound examination in the 2nd and 3rd trimesters in two-dimensional B and M mode.
Material and method/ Ultrasound examination/Fetal parameters, biometry
For two-dimensional ultrasound a Voluson E10 ultrasound machine (GE Medical Systems), and a RAB 2-5 MHz convex transducer were applied. The estimatedfetal weigh : with Hadlock B formula [7], with a computer programme, based on the values of biparietal diameter, fronto-occipital diameter , head circumference, abdominal circumference, femur length .
Material and method/ Ultrasound examination/Quantity of amniotic fluid
Its measuring takes place by applying the amniotic fluid pocket method, i.e., the distance between the body and the uterus muscle is measured in accordance in four quadrants. This provides the amniotic fluid index, according to which 1 cm distance equals the quantity of 30 cm3 amniotic fluid [8].
Material and method/ Ultrasound examination/ Fetal cardio-ultrasound
The targeted time of the fetal cardio-ultrasound is dated between the 18-23rd weeks of pregnancy [9]. Nevertheless, the focus of this research is gestational diabetes mellitus and obesity as risk factors making the fetus’ heart susceptible to development disorders, which can basically be mostly detected from the end of the second trimester [6], measurementswereimplemented from the 24th gestational week.
The basic heart-examination happens in 4-chamber view flat, when M-mode shaft is perpendicular to the interventricularis septum, at the height of the apex of bi- and tricuspid valves. The thickness of the interventricularis septum and the cardiac chamber can also be defined with this method[6,9].
The two atriums are around the same size in physiological cases, just as the two ventricles are approximately of the same size. The ventricular septum widens towards the apex cordis. In a healthy fetus its thickness grows proportionately with the advance of pregnancy, however, in pathological cases like maternal diabetes mellitus it may thicken [6].
Material and method/ Ultrasound examination/ Flowmetria
We examined the flow parameters of the uterinaland umbilical arteries by analysing the wavelength appearing on screen, especially the pulsatility index (PI) [10].
Material and method/ Selection criteria of pregnant women who meet GDM criteria
Hungary accepted the FIGO2013/AIDPSG 2013/ WHO 2013 guidelines for diagnosing GDM [5,11,12]. They are in the 18-45 age range, singular pregnancy, no anatomic development disorder detected by ultrasound, no chromosome mutation
Material and method/ Exclusion criteria
Mother’s age under 18 or over 45, multiple pregnancy, anatomic development disorder detected by ultrasound.
Material and method/Data collection about newborns
Collecting data from MedSolution’sregistered data of patients prospectively.
Material and method/ Data analysis
Analysing the received data with PSPP computer programme (version: 0.10.2, year of release: 2016), descriptive statistics and calculations with the help of single-sample t-probe. Furthermore, making charts with Microsoft Office Excel 2016andPlotly 2016 programmes. The significancs level was p=0.05.
Results
In the following subpoints weam going to review our results and findings based on the examinations carried out during the research. We applied percentage- and average calculations, the sign ± indicated after the average score means standard deviation (SD).
Results/ Description of pregnant women based on the completed datasheets
Altogether 84 pregnant women were examined. The maternal data see in Table 1a.
In GDM cases 5% of the pregnant woman included in our examinations, on the basis ofBMI-classification defined by the [13], were slightly thin, 35% of them of normal weight, 15% overweight, 30% first-degree obese and 15% second-degree obese.
Regarding insulin therapy, it must be mentioned that 75% of pregnant women received medication in addition to being on a carbohydrate diet. As for the remaining pregnant women, in 50% of the cases pathological complications occurred, such as IUGR, pathological flow of uterinalartery and premature birth.
100% of them apply a carbohydrate diet, while 75% of them also need insulin therapy.. Also, 75% of them can register diabetes mellitus in their family anamnesis.
Results/ The results of ultrasound examinations
Comparing the interventricular septum’s average and standard deviation (0,42cm±0,13), examined by fetal cardio-ultrasound in gestational weeks 24-28, to the average and standard deviation (0,25cm±0,07) of the ourcontrol goup, we found significant discrepancy (p=0,045). We compared our control group with control group mentioned in the literature,[14], there was no significantly alteration (p=0,092). (see Figure 1)
Table 1a: Maternal characteristics
Figure 2: Anteroposterior neck x-ray.
Figure 3: Foreign body
Results
Clinical Findings: The physical examination at the time of admission, afebrile, no dyspnea, and the laboratories within normal limits,Because it is a blunt foreign body and it is possible that it is a coin due to the father's history, an ultrasound of the neck is performed in the first instance, showing an elongated image in both the horizontal and sagittal planes, approximately one and a half centimeters in length by 3 centimeters. millimeters in diameter in both planes.
Diagnostic Evaluation: In the simple x-ray of the neck and chest, round radio opacity is evident at the level of the middle third of the neck seen in the anteroposterior and lateral image.
Treatment: The operating room is scheduled for the extraction of the foreign body. In our case and in the majority of national departmental hospitals, since we do not have a gastroenterologist, the extraction of the foreign body is scheduled, which is lodged in the upper third at the level of the stricture. superior.
In the operating room, a foreign body is removed with a Foley catheter without complications.
Ultrasound as a portable diagnostic tool is a useful tool in the absence of radiological means in places where we do not have them.
Patient who is admitted to bed rest and discharged 24 hours after extraction.
Discussion
Ultrasonographic imaging is a reliable and very useful means for the diagnosis of emergency pathologies and in our case of a foreign body as a cause for consultation, knowing that the area where they frequently lodge is in the upper esophageal stricture.
Simple and basic knowledge is required to handle this portable equipment, and there are even devices with rechargeable energy if needed in inaccessible places.
The majority of foreign bodies in adults are food in 34-59% or bone 16-18%, also demonstrating dental prostheses, pills, coins, and batteries, the sensitivity of radiography has been reported in 42-80%, Computed tomography detects up to 94.7-100% sensitivity.
During the evaluation process of the case, added to the clinical symptoms, the presence of a hyperechoic image surrounded by hypoechoic structure that comprises subcutaneous cellular tissue and surrounding cartilage is evident in the sagittal (vertical) and transverse (horizontal) section image. (fig 1) Likewise, in the video it is evident in real time with a low-frequency convex transducer since due to the location of the esophagus, posterior to the trachea, it is not possible to demonstrate its structure with a high-frequency linear transducer. (Fig 2).
In the radiological image, the presence of a round image at the level of the neck is evident, present in both anteroposterior presentation (fig 3).
However, as previously mentioned, due to issues of cost, location, electrical energy, ease of transport, ultrasound today represents assessing the benefit of having it at the right time but also knowing its use.
In the following image (fig 4) we present the object that was extracted with the No.16Fr Foley probe. Under sedation and direct vision using direct laryngoscopy and Magil forceps.
The patient was kept under medical observation for 24 hours, starting a liquid diet three hours after the procedure. The diet was progressed and discharge was decided one day after admission.
Conclusions
Ultrasound is a reliable and useful tool for surgeons in the emergency room as a diagnostic method in foreign bodies of the proximal esophagus.
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